AIDS Healthcare Foundation Issues Latest Anti-PrEP Salvo

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In the wake of the Los Angeles County Board of Supervisors’ vote to develop a program that would provide countywide access to Truvada (tenofovir/emtricitabine) as pre-exposure prophylaxis (PrEP), Michael Weinstein, president of AIDS Healthcare Foundation (AHF), issued a press release raising doubts over whether physicians are confident in the HIV prevention method.

The famously combative Weinstein has a long history of battling PrEP, an effort that The New York Times has characterized as a “lonely fight.” He has been pilloried by scientists and clinicians for overlooking the science supporting Truvada as HIV prevention in favor of a political agenda. In media reports about PrEP, his is typically the sole voice of opposition.

The AHF press release points to the results of a recent survey of HIV medical providers that was published in the April edition of HIV Specialist, the magazine of the American Academy of HIV Medicine (AAHIVM). The 53-question survey of 324 AAHIVM members found that, as AHF points out, 95 percent of providers said that “concerns about adherence” to Truvada were “very important” when deciding whether to prescribe PrEP to their patients. Otherwise, 93 percent cited regular follow-up care for monitoring and counseling and 82 percent cited “the effectiveness of PrEP in preventing HIV” as major factors they weigh when considering a PrEP prescription.

“I am rather surprised that only 95 percent of the doctors in the AAHIVM survey were worried about adherence,” Howard Grossman, MD, a New York City physician with large gay patient population on PrEP, tells POZ. “Any good doctor is worried about adherence with every prescription we write for every problem. Quoting this statistic out of context is meaningless.”

Indeed, the AHF press release omits other key details of the survey’s findings, which portray HIV physicians as supportive of PrEP, although with some reservations. Of the clinicians polled, who were largely primary care physicians with both HIV-negative and HIV-positive patients, 79 percent said they were “very likely” to prescribe PrEP to men who have sex with men (MSM) and who have intercourse with an HIV-positive partner. The proportion very likely to prescribe PrEP was lower, yet not insubstantial, for other high-risk demographics: 66 percent for MSM with a partner at risk of contracting HIV; 63 percent for MSM who sometimes use condoms; and 61 percent for MSM with partners of unknown status.

AHF also cites a presentation given in February at the 22nd Conference on Retroviruses and Opportunistic Infections (CROI) by Raphael J. Landovitz, MD, MSc, an associate professor of medicine at the University of California, Los Angeles (UCLA) Center for Clinical AIDS Research and Education. AHF notes that Landovitz made reference to data provided by Gilead Sciences, which manufactures Truvada, finding that, between 2012 and 2014, there were 5,272 prescriptions written for PrEP in the United States. AHF makes clear that the Gilead data has limitations: It is based on about 39 percent of U.S. retail pharmacies and less than 20 percent of Medicaid data. But the Los Angeles-based nonprofit, which is the world’s largest purveyor of HIV-related health care, fails to point out that this figure does not include those receiving PrEP as part of a medical study, a substantial figure.

AHF’s statement also does not widen the lens to include reference to Landovitz’s own attitude toward PrEP. “We need to target [PrEP toward the] most at-risk population,” the clinician stated in his CROI presentation. “PrEP scale-up is a global health imperative as part of combination prevention efforts.” Landovitz noted that the Gilead figures showed “exponential increases” in Americans starting PrEP after the first quarter of 2014.

In a separate presentation at CROI, Robert M. Grant, MD, a professor of medicine at the University of California, San Francisco, presented recent research that suggests widespread use of Truvada among high-risk San Francisco residents. Grant, the head researcher of iPrEx, the study that first proved PrEP’s efficacy among MSM in 2010, estimated that 5,000 San Franciscans have started PrEP, with perhaps 4,000 currently taking Truvada to prevent HIV. Surveys suggest that just one in 10 of these individuals are the “worried well,” reporting no condomless sex during the previous six months and thus at low risk of acquiring HIV. The remainder are high-risk individuals, which suggests that their Truvada use may succeed in contributing to the already falling incidence of the virus in that city.

In May, POZ was the first to report that PrEP prescriptions filled through New York State Medicaid rose 272 percent between June 2014 and February 2015, from 305 to 832 people.

POZ recently polled various U.S. medical providers about their total number of current PrEP users. In New York City, the Spencer Cox Center for Health reported 200 people on PrEP; Howard Grossman’s practice had 145; and the Callen-Lorde Community Health Center had 395.These figures were all significant jumps from the year prior.

Weinstein, in AHF’s press release, says, “There appears to be a real disconnect between the hype around PrEP and the reality of what doctors—and patients—actually seem to be doing with regard to PrEP. Doctors appear to be rightly cautious and the public has not been clamoring for PrEP as a prevention tool in ways that match the rhetoric surrounding the issue.

“Every clinical study that demonstrates the pharmacological efficacy of PrEP also has shown adherence—the key to PrEP’s real world efficacy—to be a problem,” he continues. “Like it or not, adherence is part of the science, and that science still does not justify widespread deployment of PrEP as a public health intervention. We believe PrEP should remain a prevention tool used on a case-by-case basis decided upon by a provider working in conjunction with his or her patient.”

The PROUD trial, a study of daily PrEP use among 545 British MSM, recently released data showing that Truvada had an 86 percent population-level effectiveness in preventing HIV. The two previous major studies of PrEP among MSM, iPrEx and its subsequent open-label extension phase, saw respective overall effectiveness rates of 44 percent and 50 percent. PROUD, the first real-world study of Truvada among MSM, bested those figures by such a significant factor because, on average, the men in the trial apparently adhered to the PrEP regimen much better.

“Michael Weinstein and AHF continue to double down on their disinformation campaign seeking to block access to a vital tool in the battle to end the HIV epidemic,” says Grossman. “How curious that Mr. Weinstein, an administrator who does not have a medical degree and, presumably, has never written a prescription, continues to lecture doctors about what we do every day.”

“As we have seen time and again, AHF are masters of cherry picking PrEP data and spinning science and implementation with callous, cynical disregard for facts or accuracy,” says Jim Pickett, director of prevention advocacy and gay men’s health at AIDS Foundation of Chicago. “The demand for PrEP is growing exponentially. That’s factual, not creative fiction. PrEP can help us turn off the tap of new infections, and works quite synergistically with treatment provision and other safer sex interventions. Saying the world is flat in carefully crafted propaganda doesn’t make it so.”

At the seventh South African AIDS Conference in Durban this week, AHF efforts to undermine PrEP’s potential rollout in that part of the world were met with derision by activists and scientists alike. In a presentation, the president of the International AIDS Society, Chris Beyrer, MD, MPH, drew a comparison between what he characterized as AHF’s “denialism” on this issue and the AIDS naysaying that infiltrated South Africa in the 2000s. This American-born scientific skepticism led then-president Thabo Mbeki to block the introduction of antiretrovirals for people living with the virus. An estimated 330,000 lives were lost as a result.